This Angel is pissed off. I'm Nurse Anne and I work on large general medical ward in the NHS. These are the wards with the most issues surrounding nursing care. The problems are mostly down to intentional understaffing by hospital chiefs that result in a lack of real nurses on the wards.
"The martyr sacrifices themselves entirely in vain. Or rather not in vain, for they merely make the selfish more selfish, the lazy more lazy and the narrow more narrow"-Florence Nightengale

This isn't scare mongering. It is true. I have seen this very kind of thing with my own eyes. Female medical patients always get the least in the way of resources, staff and facilities. It is TRUE TRUE TRUE. Any stable patient, including surgical patients waiting for an operation can end up in a cupboard of course. But mostly it is female medical patients who are actually medically stable that get the honour.

You know I hate the Mail. But credit where credit is due and all that.

They force us to wake them up at 3AM because they want to transfer these patients to a holding area that may or may not be staffed with real nurses and get the acutes from a&e onto our ward. The holding areas are staffed with people who can handle a medically stable little old lady who is waiting for a bed. But they cannot handle the acutes from a&e and mau who are breaching the targets because we have no beds.

"Nurse Anne, just refuse to wake patients up for transfer to a cupboard" you say? I did that once because I knew that the little old ladies' families would have me for breakfast when they found out that gran was moved to a day surgery suite not equipped to handle medical patients at 3AM. The site manager did it herself (moved Granny) behind my back while I was with another patient. I was wrong to refuse however. The acute patient needed the bed more. The acute patient could have died without the bed. Gran would not have. I just didn't want to get bitch slapped by Granny's daughter. Of course I was the one left to tell the daughter that she was moved at 3AM.

Do we really have to put people in supply cupboards or hallways?

At my hospital they go to a storage hallway that is used as a day surgery suite 9-5 monday to friday. There are no commodes or bedpans. No linen. The drugs that medical patients are usually on are not there. I would find it extremely uncomfortable to sit in there all day and all night and I am a fit and healthy middle aged woman.

This is how it usually goes:

The hospital has been on alert all week because of a lack of beds. This kicks into high gear overnight when a&e clogs up with drunks. At 1 AM the bed managers realise that there are now more sick patients in a&e who need to be admitted than there are free beds in the hospital.

75% of the ward patients are medically stable and do not need to be in hospital. But they cannot be discharged.

The manager opens up a cupboard or a hallway to take these A&E patients. But she doesn't have any RN's to staff it because there isn't even enough of them on the wards to even cover ward patients. There is only one RN on each ward and those wards are full of people who need an RN. She only has untrained carers to pull off the wards and use. The sick A&E patients cannot go to the cupboard staffed by the carer. The stable ward patients waiting for discharge who aren't on any IV's or anything can go to the cupboard, staffed by the carer and the really sick patient in A&E can go to the ward with the RN. The stable patients are okay for awhile with a babysitter rather than a nurse. Of course they think that the babysitter is a nurse anyway so they are none the wiser.

The stable ward patients may have dementia, they may not be able to walk or feed themselves. It isn't due to sickness, just old age. They are waiting weeks for the social workers to see them as required before they can be discharged. They have to be declared medically stable and ready for discharge for the social worker to even think about finding time to show up onto the ward and assess. Then they have to wait weeks for a nursing home to be identified. Once that happens we wait weeks for the nursing home to come and assess the patient. In the meantime a stack of paperwork has to be filled in by the staff nurse and sent to social workers.

One nurse to 15 patients does not have time to dick around and only will attempt to do that paperwork if she gets all of her patients nursed properly. If the paperwork gets done it is because we stay over after the end of our shift to do it after a new staff nurse takes over from us. The delays in filing the necessary paperwork delays everything else. I know people think that staff nurses are sitting around doing paperwork all of the time. But in reality we blow 95% of it off and only do the crucial forms....like the ones you need to get life saving drugs that you require immediately. And that 5% is very time consuming.

Once the nursing home asseses the patient they let us know whether or not they will accept her into their facility. After that happens more forms have to be organised and completed by the RN-who has 150 meds to give and patients screaming for help. I once a saw a community social worker phone the ward and order the RN to have a long and complicated care profile form filled on for a patient he was trying to place. The RN did not have time to do it because of patient needs. An hour later, the social worker arrived at the hospital and was on the ward. He backed the RN into the corner and told her that if she didn't make these forms a priority than she wasn't a "real nurse". She was the only RN for 14 patients that day. 10 of them were acutely ill. The patient in question was stable and fit. She just needed placement in a care home because she was forgetful.

The social worker sat with a cuppa and stared the RN down until she did it. Well, actually I did it for him because my patients were okay and I felt like I could leave them long enough to fill in the profile and get the social worker off of our backs. Once upon a time we had hospital social workers who did this stuff. Now we have community social workers and hospital discharge nurses who just order the sole staff nurse for 15 needy patients to do it. Whether a patient is going home with carers 4 times a day organised by the SW, or to a care home, or to a nursing home the staff nurse has to complete a whole lot of paperwork to set any of it in motion.

That brings me to the next problemNo only is the discharge process for medical patients a mess but the fact that there are no stepdown, rehab, or nursing home beds available EVER also slows things down. Even if the nurse blows off her patients to do the social workers job for her, the fact that there is not enough community care /carers and beds really slows things down as well.

The community carers will go in 4 times a day but not at night and that is when Gladys really needs someone. The residential home has no beds but won't take Gladys because she needs two staff to walk rather than one some of the time. The nursing home won't accept her because they think she is to fit to be there. The rehab facility won't take her because she is incontinant. And there are no beds at any of these places anyway. Oh and even if there was, I don't don't have the time to sit on my ass and fill in forms for social workers to set the process in motion. It is going to take me 8 hours just focusing on the drugs to get my really sick patients treated.

In addition to all these stable patients being babysat on acute medical wards we have another problem. They have reduced the number of hospital beds (PFI anyone?), they have NOT increased any care beds, nursing home beds, rehab beds, or community carers that see to people at home. The number of elderly people out there is dramatically increasing. And we have targets that mean that 98% of patients who come through the door must be treated in an artificially compressed time window. If they are not, the hospital is punished by losing even more funding, which stops them from having any hope of actually adding more beds. They only get funding and money if they can meet these targets. No one thought to give them the beds and the staff and the support so that they could actually meet the targets. The targets have to be met before they can get any funding or have any chance of being able to build beds. Fail at the targets and your hospital actually gets fined rather than funding. So if you fail at the targets you have no chance of getting money to build the beds that you need.

Therein lies the problem.

When everything finally goes through 6 weeks after granny was declared medically stable and fit for discharge and she gets that care home bed there is another form we have to send off to the SW. Then we can arrange transport. Two days later granny will be back in a&e because of a "funny turn" i.e. a mechanical fall described by nursing home staff as a collapse and increasing confusion. She will get bloods, ecg's, a ct scan etc so that the medics can cover their asses. Maybe it looks like she brewed a nice hospital acquired chest infection while she was here two days ago. IV Tazocin is ordered.

And another little old lady who is on the ward awaiting a care package on discharge will be shoved into a cupboard to get granny number 1 out of A&E before she breaches the targets. It is decided that granny can't go back to the care home now, she actually needs a nursing home. So the whole entire process has to start again with the hospital RN working for the community social workers and filling in forms for social services.

The hospital chiefs CANNOT admit this stuff to the surrounding community because if they do, their heads will role. So they come out with garbage like "uncaring nurses" "Incompetent doctors" "too many staff off sick" and they tell the members of the public who complain that "The ward sister will call a ward staff meeting about your grandma being put in a cupboard so that they understand that this should not happen. We strive to provide the best service and are sorry about your disappointment". What a joke. Half the wards don't even have ward sisters because they retired/ran away screaming and the managers will not promote or hire anyone to "save" on labour costs.

If you have read all that well done. Can I just say something to any consultants who may be reading this? It really doesn't help matters AT ALL when you walk onto a ward and say in a loud booming voice for everyone to hear "I discharged Mrs. Smith two days ago. Why is she still here? Why haven't the nurses bothered to organise a nursing home for her yet?" Seriously man, Fuck you.

184 comments:

It's an excellent description of what happens to medical patients in probably every hospital in the kingdom. Until I got to the end of the last paragraph I thought all of us at the coalface understood the issues you have described so well. I fear your consultants are being pressurised by the managers.

The managers, most extraordinarily, seem to be oblivious to the problems you describe. One walk around your ward would make the problems very clear to them but that is something they never do. Our managers are now making us do daily ward rounds in order to ensure that patients are discharged as soon as they are medically fit. Yet, as you have clearly explained, most of these medical patients are already medically fit for discharge but cannot be discharged because they need somewhere where they can be kept warm, washed, clothed, fed and watered. That somewhere is the hospital because there is nowhere else for them to go. Why does can't the management understand that our patients need somewhere where they can be looked after?

Because those in power do not seem to grasp this key issue they are, in our area anyway, busy issuing mad plans to cut hospital beds even more. This is, of course, bound to result in even more bed crises.

There is a solution to this. We need somewhere other than hospital where these poor people can be looked after. Simple. And obvious.

When I were a lad we could send people off for a couple of weeks at convalescent homes. These were excellent places and provided step down care. I am sure such things no longer exist, and that's a great pity. The they went back to where they lived recovered and capable of looking after themselves, rather than struggling on and getting ill again. Paradoxically reinstating something like this would probably save money.

Oh so true. Yet another indication of just how little this country values the old. Social services are a wate of space in my neck of the woods also. Has got to the point where I phone the department and ask to speak to a manager rather than a caseworker and basically have to play the bitch to get them to do the paperwork. The whole system is a joke. A few weeks ago our HDU was discharging patients home (I kid you not) because we were waiting so long for surgical and medical ward beds. Had to cancel elective ops so of course I have to fill out yet another batch of forms explaining why its our fault that we couldn't discharge our patients...nothing to do with the bed manangers or the fact we run at 98% occupancy. The local paper was full of how incompetent the Trust was because of this. The trust's response? Ward staff are being lazy and not following protocols....right.

I work in a hospital in a remote location. There is one local nursing home. We are about fourteen hours from any other town with a nursing home.Our medical ward is over 50% patients waiting for placement. Some have been with us for over a year now.

I can sympathise to a degree with this cupboard situation. At my hospital, an office down the corridor from the medical admissions unit was stripped of its desks, and in its place were put 5 A&E trolleys. This became known as "medical admissions B". The idea is that it is supposed to take "stable" GP admissions.

It is open from 7am to 7pm, staffed every day by a bank RN. A bank HCA is also booked from 8-5.

There is one desk at the side of the room with a computer on to check lab results, and a pile of admissions proforma paperwork. A few vomit bowls, gloves etc. are provided. The nearest phone is in the infection control nurse's office next door. If you want to take a blood pressure, or an ECG, you have to go beg and borrow from the "real" medical admissions unit (except, of course, they're underresourced too and can never spare their machinery).

I did a bank shift there once, not really realising what I was letting myself in for. Thankfully it passed without incident, but I vowed I'd never work there again because it was so bloody dangerous - we had a patient with myasthenia gravis who was having breathing difficulties, and a couple of chest pains passed through. All this without the facility to even take a blood pressure, and if the worst came to the worst, I would have to break into the office next door to call the crash team, then go find a crash trolley from a neighbouring ward. One of my colleagues ended up being sent up there a few weeks later for an emergency intubation. Scary stuff!

The old A&E unit I used to work in had CDU attached, which was basically the same unit just without the 4 hour limit. When CDU was full which it sometimes was despite it being a 28 bay ward the poor respiratory ward attached the other side of CDU took the brunt of that, and thus the cycle continues until everyone is up to their fucking eyeballs in patients they didn't train to care for. Respiratory wards have fucking ortho patients and ortho have elderly medical patients.

The trust I work in now is a bit better for it, but one of my patients who is now stuck in a shitty ex-treatment room on my ward (they decided to actually remove the equipment from this one) was actually on a maternity ward for a day before HE came on our ward. Can you believe that. 81 year old man who had a CVA ends up in Maternity. Do you reckon midwives know much about CVA's......? Although he's pulled the short straw on my ward now being in the shitty makeshift cubicle. I tripped on my shoelace in there once and leaned on one of the walls and thought I was going to go through it onto the man in a bed just next to it. The walls were nothing much thicker than MDF! To top it off in there, it stank, because it was so hot, and there was no window. Infection control don't like fans. They attract dust. They would rather the patients just fester in there. Which they do. It's a brilliant room if you fancy a bit of C-Diff or a nice chest infection during your time in hospital. Domestics come and "deep clean" the room once every patient has left but there is nothing clean about that room. Every ward has at least 2 of these in my new trust.

ANNE - with the following statements, you have hit the nail on the head as to WHY elderly people have been dumped in cupboards like this....

"stable patients being babysat on acute medical wards"

"reduced the number of hospital beds, they have NOT increased any care beds, nursing home beds, rehab beds, or community carers that see to people at home."

"The number of elderly people out there is dramatically increasing."

"targets that mean that 98% of patients who come through the door must be treated in an artificially compressed time window."

"If they are not, the hospital is punished by losing even more funding, which stops them from having any hope of actually adding more beds. They only get funding and money if they can meet these targets."

"No one thought to give them the beds and the staff and the support so that they could actually meet the targets. The targets have to be met before they can get any funding or have any chance of being able to build beds."

"Fail at the targets and your hospital actually gets fined rather than funding. So if you fail at the targets you have no chance of getting money to build the beds that you need."

WHY CAN'T GOVERNMENT AND MANAGEMENT SEE THIS COMPLETELY OBVIOUS FCUK-UP OF A SITUATION?!?

Its a lose-lose, square peg/round hole situation for the hospitals and its staff, (and therefore for the patients!) and this is why Grannys are ending up in cupboards. Its disgusting.

Although, I must say...If I worked at that trust, shown in the Daily Fail's article, I waould have been out the doors and working in Tesco's by now, I really could not bear that.

I have had the same suspicion for a few years now. Our beloved leaders realise that the NHS is a bottomless money pit and what better way to get people to take out BUPA or PPP than to run the service into the ground? The worried well will vote with their feet, believing the BUPA commercials about "clean, private rooms" "only see a consultant" and "aftercare not an afterthought" etc etc. Once enough jump ship then the NHS will become the second tier for those who have no other alternative. Pop question then...my ICU this morning has 11 level 3 patients (so is full) our HDU has 2 level 3 patients (so 2 expensive agency nurses) and 8 wardable medical patients shared between 2 RNs and 1 HCA (guess what, no medical beds or cupboards). How many would still be on the ICU under an insurance based system? Would our fancy PFI hospital be able to opt out of providing expensive ICU care to the masses? A quick survey brings up that of our current patients, only 3 have contributed in any meaningful way in terms of NI contributions. Most are longterm alcoholic/IVDU/chronic lung disease etc etc....Now I have to grit my teeth and deal with the bed manager for medicine again. Yesterday I sent our HCA on a spy mission to the medical wing to see what was really going on (bed managers LIE LIE LIE). Turns out that around 30 patients are stuck in limbo awaiting DSS type assessments PLUS there are 90 medical outliers dotted around the hospital. Doh.

In our hospital the new medical admissions, acutely unwell, get shunted to any random ward where there might be a bed once the acute medical admissions unit fills up (i.e. by about 6pm once the discharges are gone and the new admissions have hit their peak) - unfortunately, while there are a few doctors covering the admissions unit, a single house officer covers the rest of the hospital for medicine - so as well as the 200 odd stable patients (of whom at least ten will become sick over the evening) a random number (say 5-10) of acutely sick patients get shunted to a ward where they immediately hit the bleep because a new sick patient has just been dumped on their ward with minimal handover or management plan, and 'they are very X doctor' (where X is whatever it is they came in with).

But hell, everyone knows that no one dies out of hours. I certainly didn't spend last night jumping up and down on a man discharged from endoscopy with a haemoglobin of 4 and no handover to the ward of any doctor despite his blood pouring out of his GI tract, oh no.

You are spot on anonymous. I hate taking acute patients that have been rushed out of aau without being assessed. The bed manager says "what are you complaining about, all you guys have to do is get him into a bed as mau has done all of his admit paperwork"

What I actually need to do is spend ages on a mission finding out what his happening to the guy and what has been done not been done and what needs to be done. If mau tells you that his bloods have been done that means they haven't and no blood forms have been sent.

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In an atmosphere if universal deceit telling the truth is a revolutionary act. George Orwell.

Why has Nursing Care Deteriorated

Good nurses are failing every day to provide their patients with a decent standard of care. You want to know what has happened? Read this book and understand that similiar things have happened in the UK. Similiar causes, similiar consequences. And remember this. The failings in care have nothing to do with educated nurses or nurses who don't care. We need more well educated nurses on the wards rather than intentional short staffing by management.

About Me

I am a university educated registered nurse. We had a hell of a lot of hands on practice as well as our academic courses. The only people who say that you don't need a brain or an education to be an RN are the people who do not have any direct experience of nursing in acute care on today's wards. I have yet to meet a nurse who thinks that she is above providing basic care. I work with nurses who are completely unable to provide basic care due to ward conditions.
I have lived and worked in 3 countries and have seen more similarities than differences. I have been a qualified nurse for nearly 15 years. I never used to use foul language until working on the wards got to me. It's a mess everywhere, not just the NHS.
Hospital management is slashing the numbers of staff on the ward whilst filling us up with more patients than we can handle... patients who are increasingly frail. After an 8-14 hour shift without stopping once we have still barely scratched the surface of being able to do what we need to do for our patients.

Quotes of Interest. Education of Nurses.

Hospitals with higher proportions of baccalaureate-prepared nurses tended to have lower 30-day mortality rates. Our findings indicated that a 10% increase in the proportion of baccalaureate prepared nurses was associated with 9 fewer deaths for every 1,000 discharged patients."...Journal of advanced nursing 2007

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania identified a clear link between higher levels of nursing education and better patient outcomes. This extensive study found that surgical patients have a "substantial survival advantage" if treated in hospitals with higher proportions of nurses educated at the baccalaureate or higher degree level.

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania's Center for Health Outcomes and Policy Research found that patients experienced significantly lower mortality and failure to rescue rates in hospitals where more highly educated nurses are providing direct patient care.

Evidence shows that nursing education level is a factor in patient safety and quality of care. As cited in the report When Care Becomes a Burden released by the Milbank Memorial Fund in 2001, two separate studies conducted in 1996 - one by the state of New York and one by the state of Texas - clearly show that significantly higher levels of medication errors and procedural violations are committed by nurses prepared at the associate degree and diploma levels as compared with the baccalaureate level.

Registered Nurse Staffing Ratios

International Council of Nurses Fact Sheet:

In a given unit the optimal workload for a registered nurse was four patients. Increasing the workload to 6 resulted in patients being 14% more likely to die within 30 days of admission.

A workload of 8 patients versus 4 was associated with a 31% increase in mortality. (In the NHS RN's each have anywhere from 10-35 patients per RN. It doesn't need to be this way..Anne)

Registered Nurses in NHS hospitals usually have between 10 and 30+ patients each on general wards.

Earlier in the year, the New England Journal of Medicine published results from another study of similar genre reported by a different group of nurse researchers. In that paper, Needleman et al3 examined whether different levels of nurse staffing are related to a patient’s risk of developing complications or of dying. Data from more than 5 million medical patient discharges and more than 1.1 million surgical patient discharges from 799 hospitals in 11 different states revealed that patients receiving more care from RNs (compared to licensed practical nurses and nurses’ aides) and those receiving the most hours of care per day from RNs experienced fewer complications and lower mortality rates than those who received more of their care from licensed practical nurses and/or aides. Specifically for medical patients, those who received more hours per day of care from an RN and/or those who had a greater proportions of their care provided by RNs experienced statistically significant shorter length of stay and lower complication rates (urinary tract infections, gastrointestinal bleeding, pneumonia, cardiac arrest, or shock), as well as fewer deaths from these and other (sepsis, deep vein thrombosis) complications

•Lower levels of hospital registered nurse staffing are associated with more adverse outcomes such as Pneumonia, pressure sores and death.
•Patients have higher acuity, yet the skill levels of the nursing staff have declined as hospitals replace RN's with untrained carers.
•Higher acuity patients and the added responsibilities that come with them increase the registered nurse workload.
•Avoidable adverse outcomes such as pneumonia can raise treatment costs by up to $28,000.
•Hiring more RNs does not decrease profits. (Hospital bosses don't understand this. They think that they will save money by shedding real nurses in favour of carers and assistants. The damage done to the patients as a result of this costs more moneyi.e expensive deaths, complications,and lawsuits, and complaints....Anne)

Disclaimer

I know I swear too much. I am truly very sorry if you are offended. Please do not visit my blog if foul language upsets you. I want to help people. That is why I started this blog and that is why I became a Nurse. I won't run away from Nursing just yet. I want to stick around and make things better. I don't want the nurses caring for me when I am sick working in the same conditions that I am. Of course this is all just a figmant of my imagination anyway and I am not even in this reality. Or am I?Any opinions expressed in my posts are mine and mine alone and do not represent the viewpoint of the NHS, the RCN, God, or anyone else.